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African countries attained independence in the 1960s on the basis of a broad social contract between the nationalists who inherited state power from the colonial authorities and the general populace whose support was instrumental to the success of the independence struggle. At the centre of the contract was a commitment by the nationalists to an across-the-board improvement in the lives and well-being of the populace in ways which also overcame the discriminatory restrictions that underpinned colonial social policy and opened new opportunities for social advancement. The health and educational sectors occupied a pride of place in the early investments which post-colonial governments made in the social sectors; overall, these sectors witnessed an all-round expansion in the period up to the end of the 1970s. As it pertains specifically to the health sector, the primary accent was placed on developing the infrastructure for the provision of “modern” medicine to the bulk of the populace. Indeed, public investments in the development of “traditional” medicine, the only form of medicine exclusively patronised by populace before the onset of colonialism, was almost non-existent as all attention went to the development and expansion of a modern medical sector that was structured along the dominant institutional approach introduced during the colonial period. Colonial medical policy was not only racially-structured, it also had a decisively anti-traditional edge which was reinforced by missionary perceptions of the domain of traditional medicine as an arena of “animism”, “barbarism” and “spiritual impurity”. This bias against traditional medicine which assumed the form of a campaign in some cases was built into the public policy process and carried over into the post-colonial period. In the context of the accent which was placed on the expansion of access to modern health services after independence, public investments in training for medical doctors and nurses went hand-in-hand with the construction of medical centres in the urban and rural areas for the practice of modern medicine. In many countries, the public health investments made built on similar (and, in some cases, earlier) investments by missionaries. Also, private providers were licensed as part of the accent that was placed on the expansion of the modern medical sector.
For much of the period from the 1960s to the end of the 1970s, popular access to the services offered by the modern health sector underwent an uninterrupted growth. But a question which remains unanswered is whether the prospect for the consolidation of the sector would have been strengthened if a conscious effort had been made to build on the pre-existing traditional system of health provisioning and the wealth of indigenous knowledge that had been accumulated on various diseases and their treatment. Whatever the case, as the economic crises of the 1980s began to take hold, exacerbated by the structural adjustment programmes that were introduced ostensibly to contain the crises, the social expenditure of the state suffered a sharp decline, with the health sector bearing the biggest brunt. The health infrastructure of most countries immediately began to undergo a rapid deterioration and decline which, in turn, fed into and reinforced the brain drain from the health sector as doctors, pharmacists and nurses sought greener pastures elsewhere. Both the austerity measures introduced by African governments in the early 1980s to manage their economic crises and the thrust of the adjustment programmes that were adopted under the weight of donor conditionality contained commitments to cost recovery and the introduction of user charges in the health sector; structural adjustment went a step further to incarnate marketisation as the directive principle of policy and practice. The introduction of user charges, cost recovery and other marketisation policies occurred at the same time as the real incomes of the working poor collapsed in the face of deep and repeated currency devaluations; major losses of employment took place as the public sector was first “downsized” and then “rightsized”; and a heavy inflationary spiral took hold which fuelled prices and ate into incomes. All of these added up to make the modern health sector less attractive and accessible than it once was for the generality of the populace, with implications for the health-seeking behaviour of the citizenry. Inability to afford the escalating cost of modern medicine, the absence of critical modern medical services occasioned by the collapse of the public health infrastructure, a shortage of drugs and qualified personnel in public hospitals, and a widespread decline in the quality of services increasingly made a resort to traditional forms of health provisioning an alternative for a significant proportion of the populace. Furthermore, in a season of major pandemics like HIV/AIDS which have fed into the overall environment of uncertainty felt by people in their daily lives, resort to traditional medicine was both a compulsion born out of need and an adaptive/coping mechanism.
With the modern public health system functioning at sub-optimal levels, the services offered at public health facilities increasingly exposed to an internal commercial logic which, for the average patient, meant payment for virtually every service rendered, the public health insurance system being virtually non-existent, and the culture of private health insurance highly underdeveloped, individuals and households were increasingly driven into seeking alternative modes of health provisioning that entailed a rediscovery of traditional medicine and a reinvention of traditional medical practices. There was also a growth in religiosity and faith-healing; not a few straddled the worlds of faith-healing and traditional medicine in their health-seeking behaviour. If, in the face of the growth of modern public health system in the 1960s and 1970s, traditional medicine only remained viable in rural Africa, the crises of the modern health system that began in the early 1980s has also led to its resurgence in the urban areas where the collapse of the modern health infrastructure has taken its biggest toll. Amidst the revival in traditional health systems, associations of traditional healers have also emerged to seek recognition by the state and a dialogue with the modern medical sector. Whilst the rules of entry into the burgeoning traditional medical sector are still not formally defined, the number of practitioners advertising their trade has grown tremendously. The bigger and more successful providers have made investments in production and packaging facilities that are designed to improve on hygiene and address concerns about dosage. In other words, traditional medicine has also been undergoing a self-conscious process of modernisation. This is particularly so among the traditional medicine practitioners who use herbal formulae and whose remedies target different sections of the populace according to a reading of patterns of social and spatial distribution of illness.
Participants in the 2006 session of the CODESRIA Institute on Health, Politics and Society will be encouraged to explore the various dimensions of the revival and reinvention of traditional forms of health provisioning in Africa. What changes in form, content and context have been witnessed in the practice of traditional medicine over the years? What is the exact scope of traditional medical practice in contemporary Africa? What is the current state of public policy in African countries on that form of medicine? What kinds of stigma continue to be associated with traditional medicine and what are the enduring roots of the various kinds of stigma that persist? What is the interface between traditional medicine and various kinds of ritual, religious and non-religious? How are we to understand the cosmology of traditional medicine in a way that might enable us gain an insight into the worlds of the patient and practitioner? How does policy towards traditional medicine in the contemporary period compare to the policy espoused by the colonial state? What is the current legal and social status of traditional medicine in different African countries? What kinds of investments have been made to upgrade the quality of traditional medical provision? What are the rules of entry, formal and/or informal, into traditional medical practice? Are there discernible changes in the system of apprenticeship for the training of successive generations of practitioners? What are the modes of transmission of knowledge accumulated in traditional medicine? What are the inter-connections between traditional medicine and indigenous knowledge systems, and what strategies are available for preserving and protecting such knowledge from expropriation by the private commercial agents? What segments of contemporary African societies are most served by the traditional health delivery system? What are the key factors – economic, social, political, spiritual and psychological explaining the efflorescence of traditional medicine in contemporary Africa? Which are the markets that are served by the traditional medical practitioners and how might they be classified? What forms of engagement do the traditional medical practitioners have with the state and associations of practitioners of modern medicine? The range and variety of research and policy issues associated with the on-going revival and expansion of traditional medicine is endless and various multidisciplinary entry points are required for the achievement of a balanced and holistic understanding. Prospective participants in the Institute are invited to address themselves to these different entry points and other related aspects of research on health system governance in Africa.
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